Provider Demographics
NPI:1053664276
Name:BOETTGER MUDD, DAWN MARIE
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:BOETTGER MUDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 E 22ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4977
Practice Address - Country:US
Practice Address - Phone:630-627-5000
Practice Address - Fax:630-627-5032
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178007503101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor